OCCUPATIONAL NECK & SHOULDER PAIN AND HYPERMOBILITY

Uneasy lies the head that wears a crown.

— William Shakespeare, Henry IV, Part II

Neck and shoulder pain are two of the most common kinds of musculoskeletal discomfort in Australia. When considering statistics published by Safe Work Australia (SWA) concerning the 2023 to 2024 reporting period, body stressing injuries accounted for 34.5% of all serious claims by major group of mechanism (2025). Body stressing is one of the most common causes of workplace injuries, arising from sustained or acute stress applied to a region of the body that is sufficient to cause discomfort that may or may not be accompanied by structural damage (SWA, 2023). In the same 2023 to 2024 reporting period, 1.8% of serious claims were recorded to have arisen following injury to or irritation of the neck, comparable to statistics examining the 2009 to 2010 and 2013 to 2014 reporting periods (SWA, 2016). The Australian Journal of General Practice (AJGP) finds that "Computer- and office-based occupations have the highest incidence of neck and shoulder pain, with almost half of these workers experiencing neck pain in a 12-month period" (Mouatt & Kamper, 2019). Computers and other information communication technologies (ICT) are ubiquitious in almost every job role, from a High Street barista using a touchscreen to process an order, a Northcote retailer using a terminal to manage stock, or an Alphingtonian professional working from home. Occupational Neck and Shoulder pain can also arise from manual work (Herberts et. al., 1984) such as carrying, working above shoulder level, repetitive motion (Pope et. al., 1997) and regardless of whether the work is sedentary or dynamic (Grooten et. al., 2007).

One risk factor for the development of neck pain is joint hypermobility. Joint hypermobility implies a range of joint movement that exceeds what is considered to be normal for that joint taking into consideration an individual's age, gender and ethnic background - many if not most hypermobile people may be unaware that they are hypermobile - and which can develop into joint hypermobility syndrome when it is deemed to be responsible for emerging symptoms, of which pain and instability are the most important (Grahame & Hakim, 2010). There are numerous hypothesized explanations of the development and origin of hypermobility syndromes, such as genetic components, determination of joint hypermobility by diagnostic criteria (Tinkle et. al., 2009), and identification of joint hypermobility where it co-occurs within other presentations like Postural Orthostatic Tachycardia Syndrome (Miller et. al., 2020) and functional gastrointestinal disorders (Castori et. al., 2017). There has been significant clinical and research interest in joint hypermobility owing to the recognition of the complexity of identification, assessment, and appropriate management of the sequelae arising from hypermobility-related physical complaints. Associated with hypermobilise is joint laxity - the ability of a joint or structure to be moved by an external force beyond its normal limits during an accessory motion or as a function of gravity (MacConaill, 1951). Both hypermobility and laxity may be experienced by an individual as functional instability, or a sense of mistrust in the ability of a joint or limb to remain aligned even under low-force conditions. If a person has ever worried about a joint subluxing, buckling, going out of place, giving way, or even totally dislocating, functional instability may be a factor to consider in diagnosis and management (Russek et. al., 2023). The presentation of hypermobility in clinic and with respect to discomfort should be evaluated on clinical, individual, and contextual lines with respect to the client being managed. The extent of scholarship relating to hypermobilities is extensive, deep, and evolving, (Nicholson et. al., 2022) so a deeper dive might be needed in another article.

Joint hypermobility has been recognised as a risk factor for the development of musculoskeletal pain. Considering the development of musculoskeletal pain during adolescence, those study participants presenting with musculoskeletal pain at under 14 years of age had a 100% increased risk of reporting troublesome shoulder, knee or ankle and foot pain at just before 18 years of age (Tobias et. al., 2013). Within this study, this discomfort was reported in the neck and shoulder in 8.6% and 9.5% of the participants, respectively. Where an older cohort was examined, those study participants with Generalised Joint Hypermobility (GJH) and shoulder hypermobility were 1.5 to 3.5 times more likely to experience upper body musculoskeletal pain as well as being 1.6 to 4.4 times more likely to be inhibted from participating in activities owing to shoulder and neck pain (Kuul-Kristensesn et. al., 2017). The effect of discomfort and inhibitory intensity of the impact experienced by patients may be so significant as to develop into chronic pattern pain (Kumar & Lenert, 2017). There are several structural and pathophysiological hypotheses as to why this may be the case, from abnormalities in fascial thickness and the dynamics of muscles giving rise to altered tissue stiffness and functional impairments (Wang et. al., 2025), altered joint stability owing to poorer tissue stiffness (Rombaut et. al., 2012), both of which contribute to decreased muscle strength and instability (Jindal et. al., 2016). Epidemiological investigation of the relationship between joint hypermobility and the development of musculoskeletal pain generally as well as pain in the neck may be complicated by co-occurrence with other musculoskeletal symptoms, psychological stress, and reporting factors which may explain some of the contradictory or otherwise inconsistent findings relating to the detection of joint hypermobility generally, especially in early childhood (Ståhl et. al., 2008), as well as identified gaps in knowledge regarding diagnosis, screening, and triaging of neck pain for characteristics that may suggest the presence of joint hypermobility (Russek et. al., 2023). The result of this is that diagnosis of hypermobility by a clinician and its subsequent management may be poorly directed or unconsidered - many people whose discomforts are owing to hypermobility syndromes may remain ignorant of this fact.

Despite the crystallising state of the evidence with respect to the diagnosis, treatment, and longterm management of hypermobility and musculoskeletal pain, there has been less investigation into the relationship of hypermobility and the development of neck pain in workers. There is an ecosystem of individual, occupational, organisational, social, and functional determinants that can predispose a worker to or protect a worker from the development of neck pain (Ståhl et. al., 2008; Côté et. al., 2009). When considering occupational factors that may give rise to neck pain, an analysis of Portuguese office workers indicated that age over fifty years, sustained sustained postures, poor office ergonomics, and the use of laptops in combination with screens or the use of multiple screens more generally were positively correlated with the likelihood of developing neck and shoulder pain among other physical discomfort (Nunes et. al., 2021). While research continues to be sparse, there is establishd evidence that individuals with hypermobile joints may be more vulnerable to strain from repetitive movements, as well as present with significantly higher incidence of discomfort and pain in the back, neck, and shoulders (Mangram, 2003). Conversely, while considering industrial workers, those participants with hypermobility displayed increased prevalence of lower back discomfort in sitting and standing work when compared with non-hypermobile participants, while those with hypermobility displayed less back pain in dynamic and posturally diverse tasks when compared with non-hypermobile participants (Larsson et. al, 1995). This is further substantiated by studies finding that participants with diagnosed joint hypermobility present with poorer muscular endurance overall compared with non-hypermobile participants when holdings postures (Reddy et. al., 2022). The colloquial worth of this finding is illustrated in the increased ability of gymnasts, dancers, musicians, and craftspeople whose hypermobility may confer a situational advantage to their capability (Mangram, 2003). This introduces the notion that it may be possible to design job roles and tasks to accommodate workers whose joint hypermobility may predispose them to the development of musculoskeletal pain in specific occupations, while engaging those workers whose hypermobility may in fact improve their fit in certain work.

This does however remain a problem given the ubiquity of static tasks in skilled work. Knowledge workers, professionals, managers and consultants typically complete their work sitting down in one place for extended periods of time. Accommodations to the physical work environment, the use of assistive technology, changes in job requirements, and personal assistance have been noted in the literature as ways to support workers with mobility and dexterity impairments (Zolna et. al., 2007). The focus then expands to those other symptoms experienced by workers with joint hypermobility and hypermobility syndromes. It has previously been noted that pain arising from hypermobile joints can co-occur with dizziness, nausea, headaches, and other physical symptoms as a consequence of hypermobility being comorbid with other conditions. To this end, accommodations for workers with hypermobilities should not only consider the physical but the environmental, organisational, and occupational elements of the task. While the state of evidence regarding the effectiveness of exercise-based rehabilitation for the management of discomfort associated with benign as well as irritable hypermobility ranges from limited (Palmer et. al., 2014) to being effective when proprioceptive interventions are used (Smith et. al., 2014), interventions at the workplace and workforce level are less understood or structured. While it is clear that there are relationships between occupational demands, postures, and the development of discomfort, and that the intensity of this discomfort may be more significant in those with hypermobility, there is no quick fix.

The Hierarchy of Control for Risk Management encourages the identification, assessment, and control of hazards which may affect the health and wellbeing of workers (SWA, n.d.). In this case, simple ergonomic interventions such as variable position desks may alleviate the exposure of workers to static and stereotyped postures that may give rise to discomfort from accumulated tension. Additionally, affording workers the opportunity to change posture, change work, and move around their environment may be useful as well. For workers with neck pain and who are also hypermobile, the arrangement of the working area in terms of the screen and its peripherals, other devices such as pones, scanners, printers, and binders, as well as the type of chair used are all points of intervention. These are all stereotypical ergonomic interventions, which should also be undertaken with consideration for the environment such as the illumination of the workspace, the temperature of the room, airflow in the room, background and ambient noise, as well as the fluctuating demands of work. People with hypermobility are people, after all, and any factor that can predispose another worker to develop stress, strain, and symptoms can do the same for workers with hypermobile joints. Workplace health and safety professionals should bear these principles in mind for basic risk and comfort management, and consider the supplementation of these measures with targeted physical therapy delivered either by an occupational physiotherapist, occupational therapist, or a nurse to oversee a process of work-hardening for clients who may benefit from it the most. To this end, workers who report neck discomfort from sustained postures but who do not respond well to purely ergonomic intervention may benefit from screening from a physiotherapist or occupational therapist. Similarly, if a person's neck and shoulder discomfort are reliably occurring within static postures and they present with symptoms common to the ecosystem of complaints that can accompany hypermobility, such as laxity, clunking, fatigue on standing, and a feeling of instability, then they may benefit from similar screening and review of tasks. While rehabilitation principles may be informed by evidence in a clinical environment, application of those principles in an occupational environment may be less practical owing to the need to do work in working spaces and from the lack of appropriate organisational support.

Taken together, occupational neck and shoulder pain in people with hypermobility is seen to arise from an interplay of individual biomechanics, task demands, and workplace conditions. Hypermobility can heighten vulnerability to strain in static or repetitive work, yet may confer advantages in roles requiring flexibility or fine motor control. This reinforces the need for clinicians and organisations to approach assessment and management through a broad lens that considers physical, environmental, and organisational contributors to discomfort. Thoughtful task design, ergonomic optimisation, opportunities for movement, and access to targeted rehabilitation can help reduce risk and support sustained participation at work. Ultimately, recognising hypermobility as one factor within a wider system allows for more precise, practical, and person‑centred strategies to maintain worker health, wellbeing, and sustainable participation through work and life. The human body is the machine with which people interact with the world around them, the means by which they engage with life's labour and leisure, and whose capacities may wax and wane over the span of a human life. For those whose responsibility it is to design environments, tasks, and work that allow the human body to participate comfortably, and for those whose responsibility it is to maintain that participative capacity, there are as many means of protecting the human body as there are human bodies deserving of protection, as everyone's body is different, and everyone's body is theirs.

Alex Phillipos

B-Sci, B-HSci, GD-OHS, M-PHTY, M-ESH, M-OHT

Atlas Physio

2 Bruce Street, Preston

Melbourne, VIC, 3072

None of this information constitutes medical, legal, occupational health and safety, best guidance, standard, or other guidance, instruction, or prescription.

No artificial intelligence or assistive intelligence was used in the creation of this work.

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